NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Comfort Level
* Medication Response
* Pain Control
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Analgesic Administration
* Conscious Sedation
* Pain Management
* Patient-Controlled Analgesia Assistance
NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.
* Defining Characteristics: Patient reports pain
* Guarding behavior, protecting body part
* Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact)
* Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness)
* Facial mask of pain
* Alteration in muscle tone: listlessness or flaccidness; rigidity or tension
* Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)
* Related Factors: Postoperative pain
* Cardiovascular pain
* Musculoskeletal pain
* Obstetrical pain
* Pain resulting from medical problems
* Pain resulting from diagnostic procedures or medical treatments
* Pain resulting from trauma
* Pain resulting from emotional, psychological, spiritual, or cultural distress
* Expected Outcomes Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.
* Assess pain characteristics:
o Quality (e.g., sharp, burning, shooting)
o Severity (scale of 1 to 10, with 10 being the most severe) Other methods such as a visual analog scale or descriptive scales can be used to identify extent of pain.
o Location (anatomical description)
o Onset (gradual or sudden)
o Duration (how long; intermittent or continuous)
o Precipitating or relieving factors
* Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.
* Assess for probable cause of pain. Different etiological factors respond better to different therapies.
* Assess patient’s knowledge of or preference for the array of pain-relief strategies available. Some patients may be unaware of the effectiveness of nonpharmacological methods and may be willing to try them, either with or instead of traditional analgesic medications. Often a combination of therapies (e.g., mild analgesics with distraction or heat) may prove most effective.
* Evaluate patient’s response to pain and medications or therapeutics aimed at abolishing or relieving pain. It is important to help patients express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Discrepancies between behavior or appearance and what patient says about pain relief (or lack of it) may be more a reflection of other methods patient is using to cope with than pain relief itself.
* Assess to what degree cultural, environmental, intrapersonal, and intrapsychic factors may contribute to pain or pain relief. These variables may modify the patient’s expression of his or her experience. For example, some cultures openly express feelings, while others restrain such expression. However, health care providers should not stereotype any patient response but rather evaluate the unique response of each patient.
* Evaluate what the pain means to the individual. The meaning of the pain will directly influence the patient’s response. Some patients, especially the dying, may feel that the "act of suffering" meets a spiritual need.
* Assess patient’s expectations for pain relief. Some patients may be content to have pain decreased; others will expect complete elimination of pain. This affects their perceptions of the effectiveness of the treatment modality and their willingness to participate in additional treatments.
* Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain. Some patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain.
* Assess appropriateness of patient as a patient-controlled analgesia (PCA) candidate: no history of substance abuse; no allergy to narcotic analgesics; clear sensorium; cooperative and motivated about use; no history of renal, hepatic, or respiratory disease; manual dexterity; and no history of major psychiatric disorder. PCA is the intravenous (IV) infusion of a narcotic (usually morphine or Demerol) through an infusion pump that is controlled by the patient. This allows the patient to manage pain relief within prescribed limits. In the hospice or home setting, a nurse or caregiver may be needed to assist the patient in managing the infusion.
* Monitor for changes in general condition that may herald need for change in pain relief method. For example, a PCA patient becomes confused and cannot manage PCA, or a successful modality ceases to provide adequate pain relief, as in relaxation breathing.
* If patient is on PCA, assess the following:
o Pain relief The basal or lock-out dose may need to be increased to cover the patient’s pain.
o Intactness of IV line If the IV is not patent, patient will not receive pain medication.
o Amount of pain medication patient is requesting If demands for medication are quite frequent, patient’s dosage may need to be increased. If demands are very low, patient may require further instruction to properly use PCA.
o Possible PCA complications such as excessive sedation, respiratory distress, urinary retention, nausea/vomiting, constipation, and IV site pain, redness, or swelling Patients may also experience mild allergic response to the analgesic agent, marked by generalized itching or nausea and vomiting.
* If patient is receiving epidural analgesia, assess the following:
o Pain relief Intermittent epidurals require redosing at intervals. Variations in anatomy may result in a "patch effect."
o Numbness, tingling in extremities, a metallic taste in the mouth These symptoms may be indicators of an allergic response to the anesthesia agent, or of improper catheter placement.
o Possible epidural analgesia complications such as excessive sedation, respiratory distress, urinary retention, or catheter migration Respiratory depression and intravascular infusion of anesthesia (resulting from catheter migration) can be potentially life-threatening.
* Anticipate need for pain relief. One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required.
* Respond immediately to complaint of pain. In the midst of painful experiences a patient’s perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship.
* Eliminate additional stressors or sources of discomfort whenever possible. Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.
* Provide rest periods to facilitate comfort, sleep, and relaxation. The patient’s experiences of pain may become exaggerated as the result of fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a darkened room, and a disconnected phone are all measures geared toward facilitating rest.
* Determine the appropriate pain relief method.
1. Pharmacological methods include the following: Nonsteroidal antiinflammatory drugs (NSAIDs) that may be administered orally or parenterally (to date, ketorolac is the only available parenteral NSAID).
2. Use of opiates that may be administered orally, intramuscularly, subcutaneously, intravenously, systemically by patient-controlled analgesia (PCA) systems, or epidurally (either by bolus or continuous infusion). Narcotics are indicated for severe pain, especially in the hospice or home setting.
3. Local anesthetic agents.
1. Nonpharmacological methods include the following: Cognitive-behavioral strategies as follows:
o Imagery The use of a mental picture or an imagined event involves use of the five senses to distract oneself from painful stimuli.
o Distraction techniques Heighten one’s concentration upon nonpainful stimuli to decrease one’s awareness and experience of pain. Some methods are breathing modifications and nerve stimulation.
o Relaxation exercises Techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these techniques is to reduce tension, subsequently reducing pain.
o Biofeedback, breathing exercises, music therapy
2. Cutaneous stimulation as follows:
o Massage of affected area when appropriate Massage decreases muscle tension and can promote comfort.
o Transcutaneous electrical nerve stimulation (TENS) units
o Hot or cold compress Hot, moist compresses have a penetrating effect. The warmth rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort.
* Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects. Pain medications are absorbed and metabolized differently by patients, so their effectiveness must be evaluated from patient to patient. Analgesics may cause side effects that range from mild to life-threatening.
* Notify physician if interventions are unsuccessful or if current complaint is a significant change from patient’s past experience of pain. Patients who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent analgesics.
* Whenever possible, reassure patient that pain is time-limited and that there is more than one approach to easing pain. When pain is perceived as everlasting and unresolvable, patient may give up trying to cope with or experience a sense of hopelessness and loss of control.
* If patient is on PCA: Dedicate use of IV line for PCA only; consult pharmacist before mixing drug with narcotic being infused. IV incompatibilities are possible.
* If patient is receiving epidural analgesia: Label all tubing (e.g., epidural catheter, IV tubing to epidural catheter) clearly to prevent inadvertent administration of inappropriate fluids or drugs into epidural space.
* For patients with PCA or epidural analgesia: Keep Narcan or other narcotic-reversing agent readily available. In the event of respiratory depression, these drugs reverse the narcotic effect.
* Post "No additional analgesia" sign over bed. This prevents inadvertent analgesic overdosing.
Education/Continuity of Care
* Provide anticipatory instruction on pain causes, appropriate prevention, and relief measures.
* Explain cause of pain or discomfort, if known.
* Instruct patient to report pain. Relief measures may be instituted.
* Instruct patient to evaluate and report effectiveness of measures used.
* Teach patient effective timing of medication dose in relation to potentially uncomfortable activities and prevention of peak pain periods.
* For patients on PCA or those receiving epidural analgesia: Teach patient preoperatively. Anesthesia effects should not obscure teaching.
* Teach patient the purpose, benefits, techniques of use/action, need for IV line (PCA only), other alternatives for pain control, and of the need to notify nurse of machine alarm and occurrence of untoward effects.